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:k Y <br /> FOR 0 FICE USE: APPL ATION FOR WELL OR PUMP PERMIT PERMIT NO. '7 Z• 6 <br /> (Complete in Triplicate) Date Issued: <br /> HIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 0 f <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. J�. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REEGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> QBADDRESS/LOOT ON: I� r /V• O Ell C 2 f� NPU S TRACT: l /S 0-2-5 <br /> OWNER'S NAME: PHONE:'1/3 �.ys_- 727 <br /> ADDRESS: - w -T / CITY: 1AWi1Y'= <br /> CONTRACTOR'S NAM LX-CENSE4fPHONE: <br /> INTENDED USE: IN IVIDUiF DO S C ATER� LL / / PUBLIC WATER WELL / / TEST WELL /� _ <br /> !� IRRIGATION/LIVESTOCK/AGRICULTU L WATER WE LLINDUSTRIAL WATER WELL <br /> 0 CATHODIC-�PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> E E <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ku <br /> ABANDONMENT/DESTRUCTION., METHOD TO BE USED: <br /> A <br /> ��. <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I.JkAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE -LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY dF• SAN JO IN SAND HE RUL REGT,QLATIONdF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> t ' <br /> SIGNID: A - CONTRACTOR: <br /> 1.) <br /> FOR DEPARTM T USE ONLY <br /> PHASE: I i <br /> 34 <br /> APPLICATION ACCEPTED BY,: ff _ _"Ci4' DATE: <br /> ADDITIONAL COMMENTS: <br /> 1 <br /> IR <br /> f i PHASE II I PHASE III FINAL <br /> INSPECTION BY: E DATE INSPECTION BY: DATE <br /> E H 1426 �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HE'IIALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />